**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of five residents reviewed for pressure injuries. The facility failed to: - Have a wound vac available as ordered by the hospital upon Resident #1's admission on [DATE]. - Notify their wound care specialists of Resident #1's sacral wound until 03/18/25 (8 days after admission). - Follow treatment orders for Resident #1's sacral wound. She was sent to the ER on [DATE] and diagnosed with lethargy, altered mental status, fever, sacral decubitus ulcer, and sacral osteomyelitis (infection in bone). These failures resulted in an identification of an Immediate Jeopardy (IJ) on 03/25/25 at 3:40 PM and an IJ template was given. While the IJ was removed on 03/26/25 at 3:35 PM, the facility remained out of compliance at a level of no actual harm at a scope of pattern that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including type II diabetes, compression fracture of vertebra, venous insufficiency (blood pooling in the veins) of both lower extremities, and peripheral vascular disease (a condition in which narrowed arteries reduce blood flow to the arms or legs). Review of Resident #1's admission MDS, dated [DATE], reflected a BIMS score of 12, indicating a moderate cognitive impairment. Section M (Skin Conditions) reflected she was at risk of developing pressure ulcers/injuries and had one stage IV pressure ulcer upon admission. Review of Resident #1's admission care plan, dated 03/19/25, reflected she was admitted with a stage IV pressure ulcer to her coccyx with an intervention of completing treatments as ordered. Review of an order completed by the DON, dated 03/06/25, reflected she ordered a wound vac and supplies for Resident #1 from a DME company. Review of hand-written documentation, on 03/25/25, reflected the DON followed up with the DME company regarding Resident #1's wound vac on 03/07/25, 03/11/25, 03/18/245, 03/19/25, and 03/20/25. Review of Resident #1's hospital discharge paperwork, dated 03/10/25, reflected the following: Wound to be cleansed with normal saline, wound cleanser, or sterile water. Skin prep to peri-wound. KCl transparent film and black foam to be used. Continuous therapy at 125 mmhg. Wound vac dressing changes with black foam 3 x a week and/or prn for dislodgement. Continuous wound care: Active wound care orders (from admission, onward) Regular negative pressure wound therapy Mon-Wed-Fri Wet to dry dressing daily until wound vac initiation at SNF Wound to Sacrum-Pressure Injury Stage 3 Wound Length (cm) - 5 cm Wound Width (cm) - 3.2 cm Wound Depth (cm) - 2.2 cm Review of Resident #1's physician order, no start date, reflected wound care to coccyx area: Remove dry gauze, apply saturated sterile gauze with Saline, pack into the wound, cover with dry dressing. Wound care to be performed daily until wound vac is re applied on M-W-F. Review of Resident #1's TAR, March 2025, reflected three treatments were missed - 03/16/25, 03/18/25, and 03/20/25 (Sunday, Tuesday, and Thursday). Review of Resident #1's admission skin assessment, dated 03/11/25, reflected moderate serous (clear to yellow) drainage to her stage IV sacral wound, measuring 6 cm x 3.5 cm x 3 cm. Review of Resident #1's NP progress note, dated 03/13/25, reflected the wound vac had not arrived at the facility and staff were to continue daily wound care. Review of Resident #1's weekly skin assessment, dated 03/18/25, reflected heavy sanguinous (slightly bloody or frothy) drainage to her stage IV sacral wound, measuring 6.2 cm x 4.5 cm x 2 cm. Review of Resident #1's wound assessment conducted by (wound care company [WCC]), dated 03/18/25, reflected the following: Wound: coccyx stage 4: - cleanse with wound cleanser - apply nickel thick hydrogel - replace moist gauze - secure with dry dressing or bordered dressing - Frequency of dressing changes: 3 times per week Wound location: coccyx stage 4 Primary Etiology: Pressure - stage 4 - deep tissue destruction extending to facia, muscle, and may involve bone & tendons. . Tunneling at 1 o'clock appx 1.4 cm. Evidence of Osteomyelitis: No Review of Resident #1's NP progress note, dated 03/18/25, reflected they were having a hard time getting the wound vac, but it was still in progress and staff were to continue daily wound care. Review of Resident #1's NP progress note, dated 03/21/25, reflected the wound vac had not arrived at facility and her sacral wound was noted to have slough and FM A had noticed malaise (weakness or lack of energy). Review of Resident #1's hospital records, dated 03/22/25, reflected the following: Patient History and Social Determinants: . Spoke with [Resident #1's FM A] on phone. She related history that [Resident #1] has been becoming gradually more lethargic and altered since Thursday . States that she becomes this way when she gets an infection . States that [Resident #1] has a decubitus ulcer that has been getting worse over the past several days. Was supposed to get a wound VAC but has not gotten it yet. . Final Diagnoses as of 03/23/25 0515 (5:15 AM): Lethargy, Altered mental status, Fever, Sacral decubitus ulcer, Sacral osteomyelitis . CT ab/pelvis shows sacral decubitus ulcer with associated osteomyelitis. Transferred for HLOC as she will need surgical consult and infectious disease. Observation of a picture provided by Resident #1's FM A, on 03/25/25 (time-stamped 03/02/25), revealed an open area with pink and red wound bed, no drainage or slough. Wound edges were well-defined, light pink/white. Peri-wound (area around wound) was intact, and there was some darkening of the skin. Observation of a picture provided by Resident #1's FM A, on 03/25/25 (time-stamped 03/23/25), revealed a significantly larger open area. Wound bed with small amount of pink dark red tissue visible. Yellow slough covered a large portion of the wound bed. Serosanguineous drainage visible on old dressing. Wound edge not well-defined. There were some white edges visible. Peri-wound with multiple areas of broken skin, red and dark areas. During a telephone interview on 03/25/25 at 7:40 AM, Resident #1's FM A stated she was admitted to the facility for wound care and then would be going home. She stated the staff kept telling her the wound vac was delayed but she never realized the order had never been placed at all. She stated a couple days before hospitalization, she noticed she was not acting like herself. She stated if the nursing staff had been caring for her wound appropriately, they would have seen the infection and how big it had gotten. During an interview on 03/25/25 at 11:21 AM, the ADON stated the DON had been attempting to obtain the wound vac for Resident #1 long before she was admitted . She stated they did not receive it until yesterday, 03/24/25. She stated without a wound vac, it was unacceptable for Resident #1 to have missed dressing changes. She stated it was important for daily dressing changes so eyes could be set on it daily. She stated she was not aware their wound care specialists were not notified of Resident #1's wound until a week later as the DON normally informed them of new admissions with wounds. When showed the before/after pictures of Resident #1's wounds (provided by FM A), she stated the lack of the wound vac and dressing changes could have contributed to the worsening of the wound. She stated residents who required a wound vac were those that had wounds that were more extensive. During an interview on 03/25/25 at 12:18 PM, the FNPC (from the facility's WCC) stated she made weekly wound rounds every Tuesday. She stated when she was at the facility on 03/11/25, she was not notified of Resident #1 having wounds. She stated when she got to the facility, she always asked the DON if there were any residents she needed to add to her list of assessments and she was not someone that was mentioned that day. She stated it was her expectation that she be notified immediately anytime a resident was admitted with a wound or developed one. She stated she was not the person that did the assessment on Resident #1 on 03/18/25. She stated PA B completed the assessment and that was the first time they were aware of Resident #1's wounds. She stated PA B wrote an order to apply hydrogel to the wound and continue to change the dressing on Monday, Wednesday, and Friday. She stated that was not an appropriate order as the dressing should be changed daily. She stated the order for the added hydrogel never made it into the system. She stated using the gel was more effective than Saline with removing slough from the wound. She stated it was important to change a wet to dry dressing daily because she would want to see the wound daily. She stated it could have been okay to change the dressing three days a week if the hydrogel would have been implemented because it would have helped to keep the wound moist and the gel contained hypocaloric acid. She stated it would be ideal to have obtained the wound vac before being admitted , but she understood there was a lot of moving parts. She stated a negative outcome of not having a wound vac when ordered or having missed treatments could be infection or resident decline. During an interview on 03/25/25 at 1:15 PM, the NP stated her expectations were that Resident #1's treatment orders were followed. She stated if the dressings were not being changed daily, it would be longer before slough was removed which could lead to infection, wounds worsening, or growing in size. She said normally her expectations would be for the facility to not admit the resident until they had the wound vac, but for this instance, they had a hard time obtaining it from the medical supply company. She stated residents who required wound vacs had them because their wounds were deep enough to place it and the wound vac helped the wounds to heal faster. She stated the wound vac assisted in sucking up fluids which could otherwise lead to infection. During a telephone interview on 03/25/25 at 2:03 PM, the DON stated she, the ADON, and the ADM (if necessary) were responsible for ensuring supplies, such as a bi-pap or wound vac, were obtained before a resident was admitted who required them. She stated in the past, it had taken a couple of weeks to get a wound vac. She stated she did not know how long that time it was going to take to get the wound vac for Resident #1. She stated she worked with a newer representative (from the DME company) that she had never worked with before. She stated she assumed they would have had it sooner because she kept getting told it would be there by the 03/13/25 or 03/14/25. She stated until the wound vac arrived, her expectations were for wet to dry dressings to be changed daily. She stated daily dressing changes were highly important because you do not want the wounds to deteriorate. She stated if a dressing sat on the wound too long, it could hurt the wound when it was pulled off. She stated wet to dry dressings did not heal that fast and a wound vac sucked up drainage which helped the wound drain and heal faster. She stated she was not aware dressings were not getting changed every day on Resident #1 and a negative outcome could be the deterioration of the wound, possible infection, or pain. She stated she, the ADON, or any of the nurses could notify their WCC and could not remember if they were notified when Resident #1 was admitted . She stated she never received any orders for a gel on 03/18/25 from PA B. She stated there were no order changes in the system, no hand-written orders, nor was she verbally given these orders. She stated she usually met with the FNPC before she left the facility and reviewed all assessments and any new orders. She stated even if the gel had been implemented, not doing daily wet to dry dressing changes would not meet her expectations. An attempt was to interview PA B on 03/25/25 at 2:46 PM. A returned call was not received prior to exit. Review of a text message received from Resident #1's FM A, dated 03/26/25 at 1:34 PM, reflected the following: [Resident #1] just got out of surgery, and it went well. They cut away the dead tissue and they actually had to remove her tailbone (the three small vestigial pieces that had no real function) because they were clearly infected . They will place a wound vac there to help it heal. Ultimately, she will need to see a plastic surgeon to get the wound closed up due to its size and depth. Review of the facility's Wound Treatment Management Policy, revised 11/24, reflected the following: To promote wound healing of various types of wounds, it is the policy of (facility) to provide treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the type of dressing and frequency of dressing change. Review of the facility's Pressure Injury Prevention and Management Policy, revised 11/24, reflected the following: The (facility) is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The ADM and ADON were notified on 03/25/25 at 3:40 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 03/26/25 at 8:25 AM: On March 25, 2025, a state surveyor entered the facility due to a complaint regarding a discharged resident. At approximately 3:30 pm on the same day, the facility was notified by the surveyor that an immediate jeopardy had been called and the facility is now required to submit a Letter of Credible Allegation. The facility respectfully submits this Letter of Credible Allegation pursuant to Federal and State regulatory requirements. The immediate jeopardy allegations are as follows: Issue: F-Tag 686: Facility failed to have a wound vac available for Resident #1 as ordered by the hospital upon admission on [DATE]; Facility failed to notify their wound care specialists of Resident #1s sacral wound until 3/18/25; Facility failed to follow treatment orders for Resident #1s sacral wound. Done for those affected: Resident #1 not currently residing at facility. On 3/25/2025 at 12:44 pm, wound care order discharged from Skin and Wound TAR for 3x weekly wet-to-dry dressing for Resident #1. This was completed by ADON. Identify residents who could be affected: On 3/25/2025 at 4:00 pm, Administrator and/or designee reviewed all resident charts to evaluate which residents could have been affected by this deficient practice. Five current residents identified with pressure ulcers that could be affected. After review, none of the five current residents were identified to be affected by the same deficient practice. Completed on 3/25/2025. Actions taken for all residents: On 3/25/2025 at 4:30 pm, skin assessments commenced for all facility residents. This was assigned to the ADON and/or designee. Completed at 4:30 am on 3/26/2025. On 3/25/2025 at 4:30 pm, an audit was conducted to ensure all treatments, supplies, and equipment are available for ordered wound treatments. This was assigned to the ADON and/or designee. Completed at 7:30 pm. On 3/25/2025 at 4:40 pm, a medical records review was completed for all residents to ensure the most recent weekly skin assessments were completed. This was assigned to the DON. Completed at 8:07 pm. On 3/25/2025 at 5:00 pm, a care plan audit was conducted to ensure that treatment recommendations/orders were listed within the care plan and that the care plan was being followed. This was assigned to the MDS Nurse. Completed at 11:00 pm. Actions taken to prevent further occurrence: On 3/25/2025 at 5:00 pm, Administrator (RN) and [NAME] President of Operations reviewed and updated facility policies and procedures related to skin care, wound care, and pressure injury prevention as needed. This was assigned to the Administrator and [NAME] President of Operations. Administrator and [NAME] President of Operations discussed with an independent nurse consultant (also an RN) on how to properly in-service the facility nurses. Completed on 3/25/2025 at 6:00 pm. On 3/25/2025 at 4:30 pm, an audit of all pressure relieving devices and support surfaces was commenced to ensure proper use. This was assigned to the ADON and/or designee. Completed at 4:30 am on 3/26/2025. On 3/25/2025 at 6:08 pm, Administrator (RN) provided education to all licensed nurses regarding facility policies and procedures related to skin/wound care, pressure injury prevention, and appropriate wound treatment measures. This training includes ensuring residents have the necessary pressure relieving devices and support surfaces, and their proper use. This was assigned to the Administrator. Completed at 7:05 pm. On 3/25/2025 at 6:08 pm, Administrator (RN) provided education to all licensed nurses regarding the importance of providing treatment to all residents in accordance with physician orders and care plans, appropriately documenting in the facility EHR, and properly entering treatment orders in the EHR and the resident's TAR. This was assigned to the Administrator. Completed at 7:05 pm. On 3/25/2025 at 6:08 pm, Administrator (RN) provided education to all licensed nurses regarding the importance and requirement of weekly skin assessments for all residents. This was assigned to the Administrator. Completed at 7:05 pm. Education provided by Administrator was performed at shift change to ensure the education could be provided to the maximum number of nurses face-to-face. Nurses not currently working will be called by phone to be provided said education. All nurses will be provided education prior to their next scheduled shift. This was assigned to the Administrator. Completed . On 3/25/2025 at 7:10 pm, [NAME] President of Operations provided education to administrative and admissions staff regarding the ability to admit residents to the facility if and only if the physician orders can be followed appropriately and all required equipment will be at facility for the treatment of the admitted resident. Completed at 7:25 pm. On 3/26/2025 at 8:00 am, in-services provided in regards to skin/wound care, pressure injury prevention, and appropriate wound treatment measures added to the onboarding program for nurses so that training is provided prior to administering skin and wound management. This was assigned to [NAME] President of Operations. Completed . All participants in training required to sign the sign-in sheet to confirm and acknowledge understanding of the material presented. Monitoring: DON and/or designee to complete daily treatment record and nursing documentation audits to ensure accurate and complete documentation of skin related treatments and preventative measures. To be conducted daily for 2 weeks, then 3x weekly for an additional 2 weeks. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI. DON and/or designee to audit weekly skin assessments to ensure completion in accordance with facility policies and procedures. All skin assessments to be reviewed for the next 2 weeks for all residents. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI. DON and/or designee to review and validate all changes to treatment orders. To be conducted as changes occur. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI. Administrator and/or designee to conduct daily audit on admitting residents to ensure proper notification of specialist / physician. To be conducted daily for 2 weeks, then random audits for an additional 2 weeks. If issues noted, they are to be addressed promptly. Results to be presented in monthly QAPI. The Surveyor monitored the POR on 03/26/25 as followed: Observations made on 03/26/25 at 10:59 AM and 11:53 AM revealed wound care provided on two residents without any concern of the condition of the wounds. No infection control issues noted. During interviews on 03/26/25 from 12:54 PM - 2:31 PM, three RNs and three LVNs from both shifts stated they had been in-serviced before their shifts on pressure injuries, skin integrity, risk factors, and wound prevention. They all stated if a resident was admitted with a wound or developed a wound, they needed to notify their WCC as well as the DON and ADON to ensure the residents got proper treatment. They all stated if they did not have the proper supplies upon a resident's admission, they would contact the MD immediately to get the orders changed to what was available. They stated if they did not follow physician orders, the wounds could worsen, and they needed to ensure the orders matched the treatments provided. They all stated that skin assessments were done upon admission and weekly. During an interview on 03/26/25 at 1:41 PM, the ADON stated she and all nurses had been in-serviced by the ADM on implementing wound care correctly, steps and procedure, doing wound care, ensuring they were matching orders with treatments, and the importance of wound care. She stated before new admission, administrative nurses would be reviewing the clinicals to make sure they had all of the supplies. She stated she and the MDSC conducted a full skin sweep the night before (03/25/25) with no concerns. During an interview on 03/26/25 at 2:39 PM, the ADM stated an audit of all wound care supplies was conducted the day prior (03/25/25). He stated he was in-serviced by the VPO on new admissions and if they did not have the necessary equipment, they will not accept the resident until it was obtained. He stated all staff working had been in-serviced and they were calling staff that had not worked the day before or that day (03/26/25). Review of a Care Plan Audit, dated 03/25/25 and conducted by the MDSC, reflected five residents with pressure injuries with care plans containing reference to treatment orders. Review of a Treatment Supply Audit, dated 03/25/25 and conducted by the MDSC, reflected all supplies were available per physician order for the five residents with pressure injuries. Review of an in-service entitled admission Process, dated 03/25/25, reflected the ADM, MDSC, DON, and ADON were in-serviced on the following: This in-service includes education related to the admission process and the importance of admitting residents if and only if the facility is able to follow the physician orders for all treatments and all required equipment to follow said orders will be available upon admission. Additionally, the appropriate specialists (WCC) will be notified of any skin issues upon resident admitting so that the resident can be added to the scheduled during their next visit to the facility. Review of an in-service entitled Prevention and Treatment of Pressure Injuries, dated 03/25/25 - 03/25/26, reflected nurses from all shifts were in-serviced. The ADM and ADON were notified on 03/26/25 at 3:35 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of pattern that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.